Delivery, dose, outcomes and resource use of stroke therapy: the SSNAPIEST observational study

Abstract

Background Therapy is key to effective stroke care, but many patients receive little. Objectives To understand how stroke therapy is delivered in England, Wales and Northern Ireland, and which factors are associated with dose, outcome and resource use. Design Secondary analysis of the Sentinel Stroke National Audit Programme, using standard descriptive statistics and multilevel mixed-effects regression models, while adjusting for all known and measured confounders. Setting Stroke services in England, Wales and Northern Ireland. Participants A total of 94,905 adults admitted with stroke, who remained an inpatient for > 72 hours. Results Routes through stroke services were highly varied (> 800), but four common stroke pathways emerged. Seven distinct impairment-based patient subgroups were characterised. The average amount of therapy was very low. Modifiable factors associated with the average amount of inpatient therapy were type of stroke team, timely therapy assessments, staffing levels and model of therapy provision. More (of any type of) therapy was associated with shorter length of stay, less resource use and lower mortality. More occupational therapy, speech therapy and psychology were also associated with less disability and institutionalisation. Large amounts of physiotherapy were associated with greater disability and institutionalisation. Limitations Use of observational data does not infer causation. All efforts were made to adjust for all known and measured confounding factors but some may remain. We categorised participants using the National Institutes of Health Stroke Scale, which measures a limited number of impairments relatively crudely, so mild or rare impairments may have been missed. Conclusions Stroke patients receive very little therapy. Modifiable organisational factors associated with greater amounts of therapy were identified, and positive associations between amount of therapy and outcome were confirmed. The reason for the unexpected associations between large amounts of physiotherapy, disability and institutionalisation is unknown. Prospective work is urgently needed to investigate further. Future work needs to investigate (1) prospectively, the association between physiotherapy and outcome; (2) the optimal amount of therapy to provide for different patient groups; (3) the most effective way of organising stroke therapy/rehabilitation services, including service configuration, staffing levels and working hours; and (4) how to reduce unexplained variation in resource use. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 17. See the NIHR Journals Library website for further project information.

Stroke impairment categories: A new way to classify the effects of stroke based on stroke-related impairments

“…Further evidence of the validity of the Stroke Impairment Categories is reported in other publications from this project which demonstrates that the Categories are important independent factors associated with the amount and type of therapy patients receive and outcome (in terms of disability on discharge; length of stay; mortality and institutionalisation). 10,11 Differences in the need for, and dose of therapy are in line with clinical expectations for patients in the different categories. Nearly all patients were Number of days on which patients received community-based stroke therapy Physiotherapy 7 (3,16) 8 (3,17) 6 (2,13) 7 (3,14) 7 (3,14) 4 (1,9) 5.5 (3,11) 7 (3,14) Occupational Amount (minutes) of therapy/inpatient day (mean, (sd)) Physiotherapy considered to require physiotherapy and the amount of physiotherapy provided showed a bellshaped curve, with patients in moderately impaired categories receiving most therapy, and the people in the most and least impaired categories receiving less therapy, presumably because they either could not tolerate it or did not need it.…”

“…The cohort has been detailed previously 10 but in summary, there were slightly more women than men with a mean age in the mid-seventies. Over three-quarters were independent before their strokes, −10% had a haemorrhage, 40% had a moderately severe stroke (admission National Institute of Health Stroke Scale [5][6][7][8][9][10][11][12][13][14] and 81% (n = 76,585) were fully alert (National Institute of Health Stroke Scale Level of Consciousness score = 0) on admission.…”

“…Further evidence of the validity of the Stroke Impairment Categories is reported in other publications from this project which demonstrates that the Categories are important independent factors associated with the amount and type of therapy patients receive and outcome (in terms of disability on discharge; length of stay; mortality and institutionalisation). 10 , 11 …”

Investigating the association between inpatient stroke therapy and disability, destination on discharge, length of stay and mortality: a prospective cohort study using the Sentinel Stroke National Audit Programme

“…Data from the 2014 acute organisational level audit containing trust level information (eg, staffing availability) were also matched to the patient data based on a codebook provided by SSNAP 13 14. Further details on data collection, inclusion/exclusion criteria, formatting and analysis can be found in the main report 15…”

Making Best Use of Home-Based Rehabilitation Robots

“…Physiotherapy in the acute stage can be less focused on upper-limb rehabilitation [1] as the use of the lower limbs for mobility is considered of greater importance. Conventional therapy services are resource limited and can be a source of disappointment to participants [2,3]. This is a problem for the patients who are discharged from hospital wards and need to continue to undertake rehabilitation.…”